What is the preferred treatment for sigmoid volvulus caused by a redundant sigmoid colon?

Treatment for Sigmoid Volvulus Due to Redundant Sigmoid

For sigmoid volvulus caused by redundant sigmoid colon, initial treatment is urgent flexible endoscopic decompression (if no signs of ischemia/perforation), followed by mandatory sigmoid resection during the same hospital admission to prevent recurrence. 1, 2

Initial Management Algorithm

Step 1: Assess for Surgical Emergency

• Proceed directly to emergency surgery if any of the following are present: 1, 2

  • Septic shock
  • Clinical signs of bowel ischemia or perforation
  • Peritonitis
  • Hemodynamic instability

• Emergency surgery carries 12-20% mortality but is life-saving when bowel compromise exists 2

• Resection of infarcted bowel should be performed without detorsion and with minimal manipulation to prevent endotoxin release 1, 2

Step 2: Endoscopic Decompression (If Stable)

• Flexible colonoscopy is superior to rigid sigmoidoscopy with 76% success rate, 2% morbidity, and 0.3% mortality 1
• The endoscopist must visualize and pass both transition points to confirm successful detorsion 1
• Mandatory mucosal inspection at the end of the procedure to assess viability 1
• Leave a decompression tube in place after successful detorsion 1
• Abort the procedure immediately if advanced mucosal ischemia or impending perforation is discovered—these patients need emergency colectomy 1

Step 3: Definitive Surgical Resection

This is the critical step that prevents mortality from recurrence:

• Sigmoid colectomy must be performed during the index admission after successful endoscopic decompression 1, 2, 3
• Without resection, recurrence rates are catastrophically high at 45-71%, with each episode carrying risk of ischemia, perforation, and death 1, 2, 3
• Elective sigmoid resection has only 5.9% mortality compared to 40% for emergency surgery 2
• Remove the entire length of redundant colon to prevent recurrence 1
• Primary anastomosis without stoma is typically feasible in the non-emergency setting 1, 4

What NOT to Do

Avoid non-resectional procedures (detorsion alone, sigmoidopexy, mesosigmoidoplasty)—these have 16-36% recurrence rates and are inferior to sigmoid colectomy 1

Do not discharge patients after successful endoscopic decompression without definitive surgery unless they have prohibitive surgical risk 3—61% will have recurrent volvulus at a median of 31 days, and 25% of those will require emergent colectomy 1

Special Considerations

High-Risk Patients

• Age >60 years, shock on admission, and previous volvulus episodes significantly increase mortality risk 2, 3
• Even ASA grade 4 patients can undergo successful surgery with 0% mortality when performed before gangrene develops 5
• Endoscopic fixation techniques (PEC) may be considered only for patients with truly prohibitive surgical risk, though these carry 10% major complication rates 1

Surgical Technique

• For this benign pathology, full oncological resection is not needed 2
• The main consideration is ensuring adequate vascular supply to the remnant colon 2
• Laparoscopic approach is acceptable if the surgeon is experienced, though benefits in emergency settings remain unclear 2

Conservative Management Outcomes

• Mortality after conservative treatment alone ranges 9-36% 1
• In one series, 36.4% mortality was observed in patients managed with colonoscopic decompression alone 5
• All six deaths in another series occurred in patients with established gangrene 5